A nurse assesses an older adult client who has multiple chronic diseases. The client’s heart rate is 48 beats/min. What action would the nurse take first?

Correct Answer: C

Rationale: The correct action is to assess the client's medications first. Step 1: Determine potential causes of bradycardia. Step 2: Medications are common culprits in slowing heart rate. Step 3: Assessing medications can reveal drugs like beta blockers or calcium channel blockers. Step 4: Adjusting medication regimen can potentially resolve bradycardia. This approach addresses the root cause before considering immediate interventions like external pacing or atropine administration. Option A is not proactive in addressing the client's health concern. Option B is premature without identifying the cause. Option D is not indicated without understanding the underlying reason for the bradycardia.

Correct Answer: C

Rationale: The correct answer is C because the use of accessory muscles in breathing indicates severe respiratory distress in asthma patients. This finding suggests increased work of breathing and potential impending respiratory failure. Immediate action is necessary to prevent further deterioration. A, B, and D are incorrect as they are concerning but not as critical as the use of accessory muscles, which indicates a more severe condition that requires immediate intervention.

Correct Answer: D

Rationale: The correct answer is D because assisting patients with hygiene is a task that can be safely and appropriately delegated to unlicensed assistive personnel (UAP). UAP are trained to provide basic care such as bathing, grooming, and toileting under the supervision of licensed nurses. This task does not require complex critical thinking skills or clinical judgment. Choice A is incorrect because an initial assessment of a patient requires a licensed healthcare provider due to the need for comprehensive clinical knowledge and critical thinking skills. Choice B is incorrect because determining a nursing diagnosis involves analyzing assessment data and formulating a plan of care, which requires specialized nursing education and training. Choice C is incorrect because evaluating patient progress with the nursing care plan involves interpreting data, making clinical judgments, and modifying the plan of care as needed, which are responsibilities of licensed nurses.

Correct Answer: A

Rationale: The correct answer is A: teacher. Providing education to patients ensures they understand their condition, treatment, and self-care, leading to continuity of care. Collaborator (B) focuses on working with other healthcare professionals, not directly related to continuity. Mentor (C) helps with professional growth but not directly related to patient care continuity. Advocate (D) supports patients' rights but does not directly contribute to continuity of care.

Correct Answer: D

Rationale: The correct answer is D because when a patient leaves the hospital against medical advice (AMA), signing a form releasing legal responsibility is required to protect the hospital from potential legal issues. This form documents that the patient is fully aware of the risks of leaving AMA and takes responsibility for their decision. Choice A is incorrect because hospitals have legal concerns regarding patient safety and liability. Choice B is incorrect as reimbursement of medical expenses is not the primary concern in this situation. Choice C may be helpful for follow-up care but does not address the legal implications of leaving AMA.